Prioritising the health and care workforce shortage: protect, invest, together
Authors: Kwaku Agyeman-Manu, Tedros Adhanom Ghebreyesus, Mohamed Maait, Alexandru Rafila, Lino Tom, Nísia Trindade Lima, Dechen Wangmo
Journal: The Lancet Global Health (2023)

There can be no health, health systems, or emergency response without the health and care workforce. This simple truth is evident, especially during the COVID-19 pandemic. Around 115 000 health workers died of COVID-19;1WHOThe impact of COVID-19 on health and care workers: a closer look at deaths.https://apps.who.int/iris/handle/10665/345300Date: 2021Date accessed: April 26, 2023Google Scholar one in three had anxiety and depression; and as many as half experienced burnout.2Abdul Rahim HF Fendt-Newlin M Al-Harahsheh ST Campbell J Our duty of care: a global call to action to protect the mental health of health and care workers.https://www.who.int/publications/m/item/wish_reportDate: 2022Date accessed: April 26, 2023Google Scholar High-income countries have 6·5 times more health workers per population than low-income countries.3Boniol M Kunjumen T Nair TS Siyam A Campbell J Diallo K The global health workforce stock and distribution in 2020 and 2030: a threat to equity and 'universal' health coverage?.BMJ Glob Health. 2022; 7e009316Crossref PubMed Scopus (25) Google Scholar Africa has a 4% share of the global workforce despite shouldering a quarter of the global disease burden. Growing migration of health workers to high-income countries threatens to further weaken health systems across 55 countries in the 2023 WHO health workforce support and safeguard list (SSL).4WHOWHO health workforce support and safeguards list 2023.https://www.who.int/publications/i/item/9789240069787Date: 2023Date accessed: April 26, 2023Google Scholar Chronic underinvestment in the health and care workforce, mismatches between workforce supply and demand, and poor working conditions have contributed to long-standing shortages. Women comprise 67% of the workforce yet face a 24% gender pay gap5WHOThe gender pay gap in the health and care sector: a global analysis in the time of COVID-19.https://www.who.int/publications/i/item/9789240052895Date: 2022Date accessed: April 26, 2023Google Scholar and are under-represented in decision making. Workforce demand is high and evolving—particularly in the face of climate change, major demographic shifts (ageing populations and ageing health and care workforce), and rising burdens of non-communicable diseases and health emergencies. Backlogs, attrition, and burnout following COVID-19 have spiked demand for health and care workers. The health and care workforce is projected to grow to 84 million by 2030. However, a concurrent estimated gap of 10 million health and care workers will be concentrated in the low-income and middle-income countries (LMICs) in the African and Eastern Mediterranean regions and in small island developing states.3Boniol M Kunjumen T Nair TS Siyam A Campbell J Diallo K The global health workforce stock and distribution in 2020 and 2030: a threat to equity and 'universal' health coverage?.BMJ Glob Health. 2022; 7e009316Crossref PubMed Scopus (25) Google Scholar In May, 2023, The Lancet Global Health highlighted that "health care has a dangerous shortage of workers";6The Lancet Global HealthHealth-care workers must be trained and retained.Lancet Glob Health. 2023; 11: e629Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar however, the response to this danger lacks the warranted urgency and scale. As six Ministers and the Director-General of WHO, we believe that there are three key actions we must take from the Fifth Global Forum on Human Resources for Health held on April 3–5, 2023, at the WHO headquarters in Geneva: protect, invest, together (panel).7WHOFifth Global Forum on Human Resources for Health.https://www.who.int/teams/health-workforce/about/5thglobalforum-hrhDate accessed: April 26, 2023Google ScholarPanelActions to protect, invest, together in the health and care workforceProtectIn Bhutan, given the increasing attrition of the already scarce health workforce, the country is creating a unique career and performance management system for the health workforce. This system entails the development of health sector career mapping to address motivational issues and retain health workers.Brazil is actively establishing cooperative and collaborative actions for decent work in health by reducing workplace violence based on discrimination by gender, race, ethnicity, and social class; and ensuring that health workers are appreciated through humane and sustainable policies that integrate economic development with protection and social dignity in health work. On International Women's Day, March 8, 2023, Brazil launched the Programa Nacional de Equidade de Gênero, Raça e Valorização das Trabalhadoras no Sistema Único de Saúde to combat gender and racial inequalities in support of over 2·1 million health workers and health and care students who are women.In Egypt, targeted measures have been implemented with the greater realisation that sustainable increases in health workforce investments and improving conditions are key to retaining the health workforce in the public sector and enhancing their trust in the system to combat migration. Egypt has recently introduced a package to alleviate the effect of cost-of-living increases for those working in specific sectors such as education and health. Investments will increase the allowances of the health workers and those working in university hospitals. This investment includes increasing the health professional risk allowance by almost 40%, at a cost of E£3 billion (around US$97 million); increasing emergency and similar allowances by 100% with an investment of E£1 billion (around US$323m); and 40% increases for medical graduates working in university hospitals and similar health-care facilities at a cost of E£300 million (around US$9·7 million).InvestPapua New Guinea is investing in recruiting over 7000 additional health and care workers by 2024, a 34% boost in the active workforce, many of whom will be deployed to support primary health-care facilities.Romania is engaged in a substantial health-care infrastructure investment effort, encompassing the construction of novel ambulatory centres, hospitals, and primary health-care facilities. To ensure durability of these investments, a concomitant effort is required to train, retain, and motivate the essential health and care workforce. Therefore, the Romanian government adopted the Multiannual Strategy for the Development of the Health Workforce 2022–2030, a comprehensive plan of actions and policies that must be given priority.In March, 2023, Brazil announced a R$712 million investment (around US$141·3 million) through its Mais Médicos para o Brasil programme to recruit 15 000 doctors into new jobs by the end of 2023 and expand primary health-care teams across 2028 municipalities. Brazil is also training 200 000 community health workers and endemic disease agents, and expanding residency programmes to increase access to specialists.TogetherInvestment in Ghana's health workforce output will position Ghana to manage migration more efficiently through the framework of bilateral agreements. Such an approach will generate investments to strengthen the recruitment of health and care workers in Ghana, which would otherwise have been limited by inadequate expenditure space, while also easing unemployment.Ghana is adopting the African Health Workforce investment charter that outlines evidence-based principles for tackling the health workforce challenges.Intersectoral governance is critical to Brazil's strategic action for public policy implementation. Brazil's Ministry of Health and Ministry of Education recently launched an interministeral decree on health worker education that will strengthen and open new health professional training programmes.Romania, together with 50 countries across the European region, adopted the Bucharest Declaration on March 22, 2023, to urge political action and commitment to protect, support, and invest in health and care workers across Europe and central Asia.Papua New Guinea will continue collaborating with neighbouring small island developing states and other countries in the region, to expand intercountry training and work opportunities, to increase capacity and capability of its health workforce. Protect In Bhutan, given the increasing attrition of the already scarce health workforce, the country is creating a unique career and performance management system for the health workforce. This system entails the development of health sector career mapping to address motivational issues and retain health workers. Brazil is actively establishing cooperative and collaborative actions for decent work in health by reducing workplace violence based on discrimination by gender, race, ethnicity, and social class; and ensuring that health workers are appreciated through humane and sustainable policies that integrate economic development with protection and social dignity in health work. On International Women's Day, March 8, 2023, Brazil launched the Programa Nacional de Equidade de Gênero, Raça e Valorização das Trabalhadoras no Sistema Único de Saúde to combat gender and racial inequalities in support of over 2·1 million health workers and health and care students who are women. In Egypt, targeted measures have been implemented with the greater realisation that sustainable increases in health workforce investments and improving conditions are key to retaining the health workforce in the public sector and enhancing their trust in the system to combat migration. Egypt has recently introduced a package to alleviate the effect of cost-of-living increases for those working in specific sectors such as education and health. Investments will increase the allowances of the health workers and those working in university hospitals. This investment includes increasing the health professional risk allowance by almost 40%, at a cost of E£3 billion (around US$97 million); increasing emergency and similar allowances by 100% with an investment of E£1 billion (around US$323m); and 40% increases for medical graduates working in university hospitals and similar health-care facilities at a cost of E£300 million (around US$9·7 million). Invest Papua New Guinea is investing in recruiting over 7000 additional health and care workers by 2024, a 34% boost in the active workforce, many of whom will be deployed to support primary health-care facilities. Romania is engaged in a substantial health-care infrastructure investment effort, encompassing the construction of novel ambulatory centres, hospitals, and primary health-care facilities. To ensure durability of these investments, a concomitant effort is required to train, retain, and motivate the essential health and care workforce. Therefore, the Romanian government adopted the Multiannual Strategy for the Development of the Health Workforce 2022–2030, a comprehensive plan of actions and policies that must be given priority. In March, 2023, Brazil announced a R$712 million investment (around US$141·3 million) through its Mais Médicos para o Brasil programme to recruit 15 000 doctors into new jobs by the end of 2023 and expand primary health-care teams across 2028 municipalities. Brazil is also training 200 000 community health workers and endemic disease agents, and expanding residency programmes to increase access to specialists. Together Investment in Ghana's health workforce output will position Ghana to manage migration more efficiently through the framework of bilateral agreements. Such an approach will generate investments to strengthen the recruitment of health and care workers in Ghana, which would otherwise have been limited by inadequate expenditure space, while also easing unemployment. Ghana is adopting the African Health Workforce investment charter that outlines evidence-based principles for tackling the health workforce challenges. Intersectoral governance is critical to Brazil's strategic action for public policy implementation. Brazil's Ministry of Health and Ministry of Education recently launched an interministeral decree on health worker education that will strengthen and open new health professional training programmes. Romania, together with 50 countries across the European region, adopted the Bucharest Declaration on March 22, 2023, to urge political action and commitment to protect, support, and invest in health and care workers across Europe and central Asia. Papua New Guinea will continue collaborating with neighbouring small island developing states and other countries in the region, to expand intercountry training and work opportunities, to increase capacity and capability of its health workforce. We must protect the existing workforce and reduce attrition. To attract and retain health and care workers, we must provide decent working conditions, fair remuneration, and safeguard worker rights (panel). We must prevent harm from occupational hazards, discrimination, harassment, and violence. We must tackle gender inequalities with gender-responsive policies and eliminate the gender pay gap. We call on all countries to implement the recommendations of the WHO global health and care worker compact to provide safe, healthy, supportive, and dignified conditions of work for health and care workers.8WHOGlobal health and care worker compact: technical guidance compilation.https://www.who.int/publications/m/item/carecompact#:~:text=The%20care%20compact%20sets%20out,%3B%20inclusivity%3B%20and%20safeguarding%20rightsDate: 2022Date accessed: April 26, 2023Google Scholar We must prioritise investments and position action on tackling the health and care workforce shortage at the top of the agenda. Positioning the health and care workforce as a priority investment might not be easy against the current macroeconomic context and fiscal constraints, especially given that 54 countries are in debt crisis.9Jensen L Avoiding 'too little too late' on international debt relief. Development futures series working papers. United Nations Development Programme.https://www.undp.org/publications/dfs-avoiding-too-little-too-late-international-debt-reliefDate: 2022Date accessed: April 26, 2023Google Scholar Yet this investment can and must be done to unlock health and socio-economic gains. Health and care workers should be classified as a human capital investment that improves population health, accelerates socioeconomic progress, and contributes to gender equity and human rights.10WHOWorking for health and growth: investing in the health workforce - High-Level Commission on Health Employment and Economic Growth.https://www.who.int/publications/i/item/9789241511308Date: 2016Date accessed: April 26, 2023Google Scholar Standalone capital investments in health will have little effect unless the requisite human capital investments are considered (panel). Ad-hoc, piecemeal, and short-term investments have not and will not fundamentally solve workforce shortages and challenges. We need a new formula to invest more strategically in health and care worker education, lifelong learning, employment, and retention, with a particular focus on primary health care. Increased, smarter and sustained long-term and intersectoral financing is crucial, including domestic, grant, concessional, and private sector funds. Development banks, bilateral and multilateral agencies, and philanthropic foundations must work together as co-investors backing one national plan. Finally, we must act with global solidarity and intersectoral support, and make co-investments in LMICs. All countries must respect the Global Code of Practice on the International Recruitment of Health Personnel, produce enough workforce to meet domestic needs, and prioritise investment to countries in the WHO SSL to strengthen their health systems and workforce.4WHOWHO health workforce support and safeguards list 2023.https://www.who.int/publications/i/item/9789240069787Date: 2023Date accessed: April 26, 2023Google Scholar Better managed migration and co-investment in LMICs to double their health and care workforce over the next 10 years is financially and technically feasible—but only by working across the health, finance, economic development, education, and employment sectors (panel). We underscore the unique geographies, resources, and contexts of small island developing states and the increased impacts of migration and specific challenges in health and care workforce education, regulation, and access to health across remote islands. Regional and subregional collaboration to bring together resources and leverage advocacy, education and regulatory capacities, investments, and collective action should be explored (panel). It is time for governments and investors to prioritise health and care workforce investments as a foundation of our future health and prosperity. We can and must. Urgently. KA-M, MM, AR, LT, and DW report support from WHO for travel to attend the Fifth Global Forum on Human Resources for Health held April 3–5, 2023, at WHO Headquarters, Geneva, Switzerland. K A-M is the Minister of Health in Ghana. TAG is the Director-General of WHO and declares no other competing interests. MM is the Minister of Finance in Egypt. AR is the Minister of Health in Romania. LT is the Minister of Health in Papua New Guinea. NTL is the Minister of Health in Brazil. DW is the Minister of Health in Bhutan.